Jaspal R. Singh

Systematic Review of the Efficacy of Particulate Versus Nonparticulate Corticosteroids in Epidural Injections

To systematically analyze published studies in regard to the comparative efficacy of particulate versus nonparticulate corticosteroids for cervical and lumbosacral epidural steroid injections (ESI) in reducing pain and improving function.

Driving Under the Influence of Opioids

A 45-year-old man presents to your clinic as a new patient. His medical history is negative; however, his surgical history reveals a history of an L4-S1 posterior decompression and fusion that was performed 5 years earlier. The fusion was performed for a well-established chronic left-sided L5 and S1 lumbar radiculopathy. The patient’s low back pain and left lower extremity pain improved for 3 months and then returned to his presurgical level of 7/10. Postsurgical magnetic resonance imaging shows stable fusion structure without evidence of new disk herniations, with scar tissue surrounding the left-sided L5 and S1 nerve roots. The patient refuses further surgery or interventional options. In your clinic, he fills out a Screener and Opioid Assessment for Patients with PaineRevised (SOAPP-R), and his final score is 6, which indicates low risk for opioid misuse. His examination is consistent with failed back surgery syndrome (FBSS), and you believe it is appropriate to have him start taking a low-dose opioid medication. The patient signs a controlled substance agreement (CSA) in your clinic, submits a baseline urine drug screen, and after failing to find adequate relief with noneopioid-based therapies, the patient was given a prescription for morphine sulfate extended release, 15 mg twice a day. At his follow-up visit 1 month later, he reports that this medication provides good relief and limited adverse effects. His urine drug screen is appropriate for the medication prescribed, and his state prescription database monitoring program reveals no aberrancies. He would like to continue to commute to work and asks if it is safe for him to drive while taking long-acting morphine. Drs Ameet Nagpal and Rachel Xu will argue that operating a motor vehicle while taking opioid medication is not recommended because they can cause cognitive impairment. Drs Sanjog Pangarkar and Ian Dworkin will argue that the patient is taking a stable dose of long-acting opioids and therefore, with no history of cognitive-related adverse effects, driving would be considered safe.

Short-term efficacy of sacroiliac joint corticosteroid injection based on arthrographic contrast patterns.

To determine the relationship between sacroiliac joint (SIJ) contrast dispersal patterns during SIJ corticosteroid injection and pain relief at 2 and 8 weeks after the procedure. The association between the number of positive provocative SIJ physical examination maneuvers (minimum of one in all patients undergoing SIJ injection) and the patients response to the intervention was also assessed.

Percutaneous CT-guided facet joint synovial cyst rupture: Success with refractory cases and technical considerations

Percutaneous image-guided rupture of lumbar facet synovial cysts can improve clinical outcomes and obviate the need for open surgery. This series describes eleven patients who had successful CT-guided lumbar facet synovial cyst ruptures, 82% of which experienced excellent pain relief at a minimum of one-year follow-up. Of the five patients who failed prior fluoroscopic-guided synovial cyst rupture, 80% had a successful CT-guided rupture and one-year sustained pain relief. These findings reinforce minimally invasive CT-guided treatment as an excellent option to improve patient symptoms and potentially avoid open surgery.

Comparison of Spinal Needle Deflection in a Ballistic Gel Model.

Background Percutaneous diagnostic and therapeutic procedures are commonly used in the treatment of spinal pain. The success of these procedures depends on the accuracy of needle placement, which is influenced by needle size and shape. Objectives The purpose of this study is to examine and quantify the deviation of commonly used spinal needles based on needle tip design and gauge, using a ballistic gel tissue simulant. Materials and Methods Six needles commonly used in spinal procedures (Quincke, Short Bevel, Chiba, Tuohy, Hustead, Whitacre) were selected for use in this study. Ballistic gel samples were made in molds of two depths, 40mm and 80 mm. Each needle was mounted in a drill press to ensure an accurate needle trajectory. Distance of deflection was recorded for each needle. Results In comparing the mean deflection of 22 gauge needles of all types at 80 mm of depth, deflection was greatest among beveled needles [Short Bevel (9.96 ± 0.77 mm), Quincke (8.89 ± 0.17 mm), Chiba (7.71 ± 1.16 mm)], moderate among epidural needles [Tuohy (7.64 ± 0.16 mm) and least among the pencil-point needles [Whitacre (0.73 ± 0.34 mm)]. Increased gauge (25 g) led to a significant increase in deflection among beveled needles. The direction of deflection was away from the bevel with Quincke, Chiba and Short Beveled needles and toward the bevel of the Tuohy and Hustead needles. Deflection of the Whitacre pencil-point needle was minimal. Conclusions There is clinical utility in knowing the relative deflection of various needle tips. When a procedure requires a needle to be steered around obstacles, or along non-collinear targets, the predictable and large amount of deflection obtained through use of a beveled spinal needle may prove beneficial.

Single Versus Two-Level Transforaminal Epidural Steroid Injection for Treating Lumbosacral Radicular Pain: What is the Evidence?

M.S. is a 58-year-old man presenting for evaluation of a 12-week history of low back and right leg pain radiating to the right buttocks, groin, anterolateral thigh, posterolateral calf, lateral ankle, and dorsal foot with paresthesias. His physical examination demonstrates that a right straight leg raise at 50 reproduces concordant right lower limb symptoms. Results of a hip examination are negative, including pain-free full range of motion. Findings of a sensory and motor examination are normal, and the patient has slightly diminished, symmetrical patellar and Achilles reflexes bilaterally. A recent lumbar magnetic resonance imaging (MRI) study demonstrates multilevel degenerative abnormalities, including mild to moderate foraminal stenosis at L4-L5 and L5-S1 bilaterally and a right paracentral disk protrusion at L5-S1 that is mildly compressing the right S1 nerve. Electromyography (EMG) of the right lower extremity was normal with no objective evidence of radiculopathy or neuropathy. After a trial of physical therapy and oral anti-inflammatory medications, the patient underwent an L5-S1 interlaminar epidural steroid injection (ESI) that provided 85% improvement for 4-5 days. The patient is frustrated and has requested one more injection before considering surgery. Drs Michael B. Furman and Nicholas H. Weber will advocate for a 2-level transforaminal (TF) ESI (TFESI), whereas Dr Steven P. Cohen suggests that a 1-level TFESI is sufficient to produce a therapeutic effect.

Cooled Versus Conventional Thermal Radiofrequency Neurotomy for the Treatment of Lumbar Facet–Mediated Pain

A 59-year-old woman with no significant past medical history presents to the spine clinic with right-sided lower back pain. She reports having pain off and on for 10 years with no history of trauma or injury. The pain is typically worse when she is standing in place, with some improvement upon walking and resolution of pain while sitting. The pain is localized to the right L3-L5 paraspinal and gluteal regions. Upon examination, her sensory, motor, and muscle stretch reflexes are all within normal limits. Pain is exacerbated by lumbar extension and quadrant loading toward the right. Magnetic resonance imaging of the lumbar spine reveals mild disk degeneration but evidence of facet arthropathy of the right L4/L5 and L5/S1 facet joints. She is diagnosed with lumbar facetemediated pain and is scheduled for diagnostic medial branch blocks. After positive responses (>80% reduction in pain) to 2 sets of medial branch blocks, she presents to discuss the next steps. She recently saw an advertisement for cooled radiofrequency neurotomy (RFN) and would like to consider this option. Drs Prempreet Bajaj and Jonathan Napolitano will advocate for cooled RFN, arguing that this procedure results in improved patient outcomes and is a safe procedure. Drs Wenbao Wang and Jianguo Cheng will argue that evidence of the efficacy of cooled RFN is limited and that the increased costs do not justify its use.

Image-Guided Injections of the Hip

The authors present a technique paper on the utilization of both ultrasound and fluoroscopy guidance for injections about the hip joint. This review draws from specialists including physiatry, family medicine and orthopaedic surgery. We hope the editors and reviewers find this document beneficial to the readership, especially those practicing musculoskeletal medicine and may use this information when performing hip injections. Traditional causes of hip pain may be divided into either intra- articular or extra-articular sources. The hip joint, pelvis and pelvic girdle muscles have a complex anatomical relationship with proximal and distal structures including the lumbosacral spine and the knee joint. Abnormalities in these regions may cause various referral patterns often mimicking primary hip pain ( 1). The character and location of pain is a key element in the differential diagnosis of hip pain. For instance, anterior hip or groin pain often suggests primary involvement of the hip joint itself. However, in a study conducted by Lesher and colleagues, hip joint intra-articular injections were shown to cause referred pain into the buttock (71%), thigh (57%) and groin (55%) (2). Lateral hip pain that is aggravated by direct pressure is the classic presentation of trochanteric bursitis. Referred pain from facet and sacroiliac joints as well as proximal lumbar radicular pain may also present with pain in the groin or hip. This pain typically originates at the waistline or posterior gluteal areas. The source of hip pain can be further defined by a detailed history and physical examination. However, a portion of hip pain patients may require additional diagnostic work up to further elucidate the etiology. Radiographic examinations such as plain x-ray, radionuclide scans, magnetic resonance imaging (MRI), computerized tomography (CT) or ultrasonography are useful in the investigation of the possible causes of pain around hip. In addition, several injection techniques, often performed under fluoroscopy or ultrasound guidance, are also helpful to distinguish the conditions causing hip pain. These injection techniques may be used for therapeutic purposes, functional demonstrations, or even joint aspiration. Ultrasound provides real- time radiographic imaging of the musculoskeletal system and in particular has the ability to make dynamic assessments of deep-

Refractory Knee Osteoarthritis: Adipose-Derived Stromal Cells Versus Bone Marrow Aspiration Concentrate

A 56-year-old woman presents to the clinic with a long history of right knee pain. The pain began insidiously 4 years prior and she reports a slow progression in pain and decrease in her function. She has been treated with oral analgesics and anti-inflammatories. In addition, she is currently enrolled in her third round of physical therapy. Last year she had an intra-articular corticosteroid injection, which gave her about 6 weeks of relief. Following this, she underwent a series of 3 hyaluronic acid injections (SupartzFX) that she completed 3 months ago. She reports that this injection did not provide her with significant relief. The patient reports primarily knee pain over the medial joint line. Her alignment is normal and she does not report any swelling, buckling, or locking of her knee. The pain is worse when going up and down stairs, but she does not report any falls. Radiographs and magnetic resonance imaging (MRI) of the right knee reveal moderate to severe tibiofemoral osteoarthritis (Kellen Lawrence grade 3) with mild medial meniscus fraying. There is no discrete meniscus tear, and the anterior and posterior cruciate, and medial and lateral collateral, ligaments are intact. She was reading information on the role of “stem cells” injected into the knee that could regenerate and repair her degeneration. Drs Gerald Malanga and Samuel Dona will argue for adipose-derived stromal cells (ADSCs). Drs Joanne Borg-Stein and Michael Auriemma will argue for bone marrow aspiration concentrate (BMAC).

Football Participation and Chronic Traumatic Encephalopathy

A 13-year-old male athlete presents to the clinic with his parents for a preparticipation physical examination. The athlete has participated in soccer, baseball, and track in the past but is very interested in joining the football team this year. His parents are hesitant for him to participate in football because they have heard about a brain injury in football players called chronic traumatic encephalopathy (CTE). They would like your advice regarding whether their child should avoid football due to the risk of developing CTE. The athlete is an aboveaverage student and aspires to go to college and become an engineer. He has no significant medical or surgical history. Specifically, he has never sustained a previous brain injury. He does not take any medications. He does not have a history of psychiatric disorder or learning disability. He denies smoking, drinking alcohol, or taking illicit drugs. His family history is significant for migraine headaches in his mother and maternal grandmother. Dr Scott Laker will argue that the benefits of participating in football outweigh the risks of developing CTE and would counsel the patient to participate in football if they so desire. Dr Christine Griess will argue that collision sports, especially American football, increase the chances of CTE andwould counsel the patient not to participate.